Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual
Christos P Kotanidis1,2, Gregory B Mills1,2, Bjørn Bendz3,4
1Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK.
Insights
Routine invasive treatment for older patients with non-ST-elevation acute coronary syndrome (NSTEACS) did not reduce overall mortality or myocardial infarction (MI) risk. However, it significantly lowered the risk of repeat MI and urgent revascularization.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) often receive less guideline-recommended care.
- Evidence on interventional management strategies for elderly NSTEACS patients is limited.
- This study addresses the scarcity of data on invasive vs. conservative strategies in this population.
Purpose of the Study:
- To assess the impact of routine invasive versus conservative management in older patients (>70 years) with NSTEACS.
- Utilized individual patient data (IPD) from randomized controlled trials (RCTs).
- Evaluated the primary endpoint of all-cause mortality and myocardial infarction (MI) at 1 year.
Main Methods:
- Systematic literature search of MEDLINE, Web of Science, and Scopus (2010-2023).
- Included RCTs comparing routine invasive and conservative strategies in NSTEACS patients >70 years.
- Employed one-stage IPD meta-analysis using random-effects and fixed-effect Cox models.
Main Results:
- Six RCTs with 1479 participants were analyzed.
- No significant difference in the composite endpoint of all-cause mortality and MI at 1 year (HR 0.87, P=.43).
- Significantly lower hazard for MI (HR 0.62, P=.006) and urgent revascularization (HR 0.41, P=.037) in the invasive group.
Conclusions:
- Routine invasive treatment for NSTEACS in older adults does not reduce 1-year all-cause mortality or MI composite risk.
- Invasive management significantly reduces the risk of repeat MI and the need for urgent revascularization.
- Further research from ongoing large clinical trials is warranted.
Background And Aims:
Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients.
Methods:
MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819).
Results:
Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63-1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44-0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18-0.95; P = .037). There was no significant difference in mortality.
Conclusions:
No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials.
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